PRIMARY INSURANCE

SECONDARY INSURANCE

If Yes, Please list medications and reason for taking them:

I authorize the dentists of Perry Dental and/or such associates or assistants as she/he may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other
individual for which I have responsibility.

I understand that the administration of local anesthetic may cause an outward reaction or side effects, which may include, but are not limited to bruising, hematoma, cardiac stimulation, temporary or rarely permanent numbness, and muscle soreness.

I understand that there are risks associated with ALL dental treatments including, but not limited to: permanent numbness, pain, swelling, and unsuccessful treatment, etc. I understand that as a result of dental treatment including preventative procedures such as cleanings and basic dentistry, as well as fillings of all types, the teeth, gums, and surrounding areas may remain sensitive or even possibly quite painful both during and after completion of treatment.

CONSENT FOR TREATMENT I hereby grant authority to the dentist(s) in charge of the patient whose name appears on the Health History Form to administer any treatment or to administer such anesthetics, analgesics, sedatives, and nitrous oxide sedation, and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of the patient. I have read the above terms and conditions and consent for treatment and fully agree to their content.

I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventative and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions.

Thank you for choosing us as your dental care provider. We are committed to your treatment being successful and to providing the highest quality dental services at a reasonable fee. Please understand that payment of your bill is necessary in order for us to provide treatment.

Patients with Dental Insurance
As a courtesy to our patients, we prepare and process all insurance forms. However, having insurance does not release the payment from responsibility.
Our expectations of you as the owner of the policy are as follows:

1. Estimated patient portions must be paid at the time of service. This may include co-pays, deductibles, co-insurance and/or non-covered procedures.
2. You are responsible for educating yourself about the details of your policy which includes deductibles, yearly maximums, and policy exclusions.
3. If the insurance company does not pay our office within 60 days, it is your responsibility to pay using one of the payment methods listed below. The insurance policy belongs to you and we have no leverage to obtain payment. A finance charge of 1.5% per month (annual percentage rate 18%) will be assessed on any unpaid balance over 60 (sixty) days regardless of insurance estimates. Insurance estimates are based on limited information provided to our office by your insurance company and is not a guarantee of coverage or payment.

Patients without Dental Insurance
If there is no insurance coverage, full payment is due at the time of service with one of the payment methods listed below.

Payment Options
For your convenience you may choose any of the following methods of payment:

• Cash
• Personal Check (postdated if necessary)
• Visa, MasterCard, Discover, American Express-Credit or Debit
• Care Credit (short-term plans are available with no interest). Credit approval must be received prior to treatment.

Broken & Missed Appointments
Please make every attempt to keep your scheduled appointment. If you must cancel or reschedule, kindly notify us a least 48 hours in advance. There will be a $50 cancellation fee applied to your account for any appointment broken within 48 hours of your scheduled appointment time.

X-ray Copies
Here at Perry Dental we use digital x-rays. Digital x-rays use minimal radiation compared to traditional x-rays and are available upon request.

Minor Patients
The parent, guardian, or adult accompanying and signing all forms for a minor will be responsible for full payment. Parents or guardians must be present to authorize all dental treatment to minors.

Financial Agreement
I understand that I am financially responsible for all charges incurred by my dependents and myself whether or not covered by insurance. I hereby authorize Perry Dental Associates to use the following signature for proof of signature on insurance claim forms for assignment of insurance payment and release of information. I agree to pay Perry Dental Associates professional services rendered to me at the time of service. If my insurance pays less than estimated, I agree to pay any remaining balance within 30 (thirty) days of billing. I expressly agree to pay all costs of collection agency fees assessed at 40% of the total amount due as well as court costs and attorney fees if these terms are not met.

OUR LEGAL DUTY

We are required by applicable federal and state laws to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, and our legal duties and your rights concerning your health information. We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including information we created or received before we made the changes.

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

• Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
• Payment: We may use and disclose your health information to obtain payment for services we provide to you.
• Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare includes quality assessment and improvement activities, reviewing the competence or qualification of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.
• Your Authorization: You may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.
• Your Family and Friends: We must disclose your health information to you, as described in the patient rights section of this notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or payment for your healthcare, but only if you agree that we may do so.
• Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or other person responsible for your care, of your location, your general condition, or death. We will also use our professional judgement and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
• Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
• Required by Law: We may use or disclose your health information when we are required to do so by law.
• Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or the possible victim of other crimes.
• National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances.
• Appointment Reminders: We may use or disclose your health information to you with appointment reminders such as voicemail messages, postcards, texts, or letters.

PATIENT RIGHTS

• Access: You have the right to look at or get copies of your health information, with limited exceptions. We will use the format requested unless we cannot practically do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time.
• Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and other activities for the last 6 years. We may charge you a reasonable cost-based fee for responding to these additional requests.
• Restriction: You have the right to request that we place additional restrictions on our disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
• Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you requested.
• Amendment: You have the right to request that we amend your health information (your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances.
• Electronic Notice: If you receive this notice on our website or by e-mail, you are entitled to receive this notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy rights, or you disagree with a decision we made about your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may contact us using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint.

By signing below, you agree to the following:

• I have read and/or received a copy of this office’s Notice of Privacy Practices. 
• I consent to text messaging and billing (A paperless communication method).
• I grant Perry Dental rights to the use of my (or the individual for whom I am signing if a minor) pictures, photographs, or images in all forms of media for educational or marketing purposes and release Perry Dental from any liability or from any claim of compensation.